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|
Attributes | |
ACN | 583146 |
Time | |
Date | 200305 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : bae.vortac |
State Reference | MA |
Altitude | msl single value : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zbw.artcc tracon : pct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zbw.artcc |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 225 flight time total : 15200 flight time type : 2900 |
ASRS Report | 583146 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 125 flight time total : 14000 flight time type : 600 |
ASRS Report | 583577 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : heading select other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory |
Miss Distance | horizontal : 30000 vertical : 0 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While climbing through approximately 13000 ft MSL en route direct baf VOR, we were given instructions to climb to FL230 and turn left to heading of 280 degrees. I put both numbers into their respective position in the mode control panel, but failed to immediately select 'heading select' on the heading switch. Consequently, the airplane continued direct baf VOR. Approaching approximately 17000 ft MSL, the controller asked if we were heading 280 degrees. At that time I selected 'heading select,' initiated the turn, and observed on TCASII an aircraft at approximately 4 O'clock position and 5 mi, 1600 ft MSL below our altitude. I'm not certain if the traffic I observed was the proximate traffic which necessitated the vector, or if that traffic at any point drew closer than when I observed it on TCASII. Before reaching a heading of 280 degrees, center directed us to proceed direct baf VOR. The error was caused by my failure to remember to push the 'heading select' switch after dialing in the heading, and my follow-on failure to verify that 'heading select' was indicated on the attitude direction indicator, verifying the airplane was doing what I wanted it to do. The most apparent solution is to exercise the discipline to always check the expected result of an input to the airplane's automation. Supplemental information from acn 583577: the heading was now selected. Center called our traffic at our current altitude, 2 O'clock position and 5 mi. We did not see it. My partner made a procedural error in that he did not activate the 'heading' mode. I also failed to back him up to confirm the activation. Our airline has done a good job of training its pilots to 'double point' at the altitude and heading windows when set. We need to also ensure that the aircraft does what we think we told it to do.
Original NASA ASRS Text
Title: B757-200 FO FAILS TO ENGAGE HEADING SELECT WHEN ISSUED VECTORS AND ALT CLB BY ZBW RESULTING IN A ZBW CHALLENGE AND TFC PASSING AT SAME ALT AND 5 MI.
Narrative: WHILE CLBING THROUGH APPROX 13000 FT MSL ENRTE DIRECT BAF VOR, WE WERE GIVEN INSTRUCTIONS TO CLB TO FL230 AND TURN L TO HEADING OF 280 DEGS. I PUT BOTH NUMBERS INTO THEIR RESPECTIVE POS IN THE MODE CTL PANEL, BUT FAILED TO IMMEDIATELY SELECT 'HEADING SELECT' ON THE HEADING SWITCH. CONSEQUENTLY, THE AIRPLANE CONTINUED DIRECT BAF VOR. APCHING APPROX 17000 FT MSL, THE CTLR ASKED IF WE WERE HEADING 280 DEGS. AT THAT TIME I SELECTED 'HEADING SELECT,' INITIATED THE TURN, AND OBSERVED ON TCASII AN ACFT AT APPROX 4 O'CLOCK POS AND 5 MI, 1600 FT MSL BELOW OUR ALT. I'M NOT CERTAIN IF THE TFC I OBSERVED WAS THE PROXIMATE TFC WHICH NECESSITATED THE VECTOR, OR IF THAT TFC AT ANY POINT DREW CLOSER THAN WHEN I OBSERVED IT ON TCASII. BEFORE REACHING A HEADING OF 280 DEGS, CTR DIRECTED US TO PROCEED DIRECT BAF VOR. THE ERROR WAS CAUSED BY MY FAILURE TO REMEMBER TO PUSH THE 'HEADING SELECT' SWITCH AFTER DIALING IN THE HEADING, AND MY FOLLOW-ON FAILURE TO VERIFY THAT 'HEADING SELECT' WAS INDICATED ON THE ATTITUDE DIRECTION INDICATOR, VERIFYING THE AIRPLANE WAS DOING WHAT I WANTED IT TO DO. THE MOST APPARENT SOLUTION IS TO EXERCISE THE DISCIPLINE TO ALWAYS CHK THE EXPECTED RESULT OF AN INPUT TO THE AIRPLANE'S AUTOMATION. SUPPLEMENTAL INFO FROM ACN 583577: THE HEADING WAS NOW SELECTED. CTR CALLED OUR TFC AT OUR CURRENT ALT, 2 O'CLOCK POS AND 5 MI. WE DID NOT SEE IT. MY PARTNER MADE A PROCEDURAL ERROR IN THAT HE DID NOT ACTIVATE THE 'HEADING' MODE. I ALSO FAILED TO BACK HIM UP TO CONFIRM THE ACTIVATION. OUR AIRLINE HAS DONE A GOOD JOB OF TRAINING ITS PLTS TO 'DOUBLE POINT' AT THE ALT AND HEADING WINDOWS WHEN SET. WE NEED TO ALSO ENSURE THAT THE ACFT DOES WHAT WE THINK WE TOLD IT TO DO.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.